Fillable Form 1.: Virginia Voter Registration Application (Pittsylvania County Virginia)

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Form 1.: Virginia Voter Registration Application (Pittsylvania County Virginia)

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The Form 1.: Virginia Voter Registration Application (Pittsylvania County Virginia) form is 2 pages long and contains:

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  • 11 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Pittsylvania County Virginia

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VA-NVRA-1 04/16
Starred (*) items are required. If you do not complete all of the items that are marked with *, your application may be denied (See instructions on reverse side).
Virginia Voter Registration Application
AFFIRMATION: I swear/affirm, under felony penalty for making willfully false material statements or entries, that the information provided
on this form is true. I authorize the cancellation of my current registration and I have read the Privacy Act Notice.
By checking this box, I a rm both that I am an individual with physical disabilities and the A rmation Statement above. Pursuant to
Article II, § 2 of the Constitution of Virginia, individuals with physical disabilities are not required to sign the application for voter registrations.
*
Signature
*
Virginia Voter Registration Application Receipt
#
The application collector must submit your
completed application within 10 days or by the
deadline to register for the next election, whichever
comes  rst. You can check your voter registration
status online at elections.virginia.gov/register .
If you do not receive con rmation of your voter
registration status within 30 days, contact your local
voter registrar or the Virginia Department of Elections.
YES NO
*
Have you ever been convicted of a felony or
judged mentally incapacitated and disquali ed to vote? .........
YES NO
If YES, has your right to vote been restored?
.......
YES NO
*
Full social
security
number
*
I am a citizen of the
United States of America.
Name, phone and e-mail of o ce, group or individual
receiving application
I am providing a Virginia P.O. Box (below) to protect my residence address from public disclosure because:
I am an active or retired law enforcement o cer, judge, U.S. or Virginia Attorney General attorney
I have a court issued protective order for my bene t
I have evidence of  ling a complaint with law enforcement that either I or a household member is in fear for personal safety
from another person who has threatened or stalked either me or a household member
I am a participant in the Virginia Attorney General’s Address Con dentiality Program
6.
I am interested in being an Offi cer of Election (poll worker) on Election Day. Please send me information.
Use blue or black ink
*
Date of
birth
/ /
D D
MM
Y YY
Y
D D
MM
Y YY
Y
Today’s date:
/ /
D D
MM
Y YY
Y
Date application received
/ /
D D
MM
Y YY
Y
I am an active-duty uniformed services member, spouse or dependent; or an overseas citizen.
7.
Thank you for applying
to vote in Virginia!
*
Gender
3.
I am providing a mailing address (below) because my residence address is not serviced by the U.S. Postal Service or I am homeless.
4.
*
Residence address (May not be a P.O. Box)
*
City/Town
Apt #
*
Last name
*
First name
2.
Jr. Sr. II III IV (Circle if applicable)
*
ZIP
E-mail
*
Middle name
N
-
-
Phone
N N
N N N
N N
N
NN
None
-
-
NNNN
N
N
NNN
No SSN was ever issued.
5.
My mailing address (Complete only if you have checked a box in this section)
I am currently registered to vote in another state: .
(
Indicate state of previous registration)
1.
MAIL TO: General Registrar - PO Box 208 - Gloucester, VA 23061
Suffix: None
VA-NVRA-1 04/16
Virginia Voter Registration Application
When registering to vote, Article II, Section 2 of the Constitution of Virginia (1971) requires you to provide your social
security number, if you have one. If you do not provide your social security number, your application will be denied.
Voting ocials use the social security number as a unique identier to ensure that no voter is registered in more than
one place.
Your application will only be open to inspection by the public if the social security number is removed. Your social
security number will appear on reports produced only for ocial use by voter registration and election ocials, for
jury selection purposes by courts, and all lawful purposes. Your decision to decline to register to vote as well as the
oce where you submit your application, if you choose to do so, are condential and will only be used for voter
registration purposes.
With this form, you can register to vote in elections in Virginia. You can also use this form to change the information
on your Virginia voter registration.
If you are currently registered to vote, you do not have to use this form unless you have moved or changed your
name.
ATTENTION: Overseas citizens, uniformed service voters, qualifying spouses and dependents may register using the
Federal Post Card Application (FPCA), available at www.fvap.gov .
Register to
Vote
Your Address
You must provide a street address or description of your physical dwelling place as a residence address. If your
residence address is not serviced by the U.S. Postal Service, or if you are homeless, you can list a mailing address in
Box 4. Overseas citizens, uniformed service members, qualifying spouses and dependents can list a mailing address
in Box 4. If you are a qualied protected voter, you must list a Virginia post oce box to protect your residential
address from public disclosure in Box 4. No other applicant can list a mailing address.
How to Mail
Mail your completed application to your local registrar. Use the online address lookup tool if you do not know your
registrar’s address: elections.virginia.gov/localGR or mail your application to:
Virginia Department of Elections
1100 Bank Street
Richmond, VA 23219
Mailed applications must be postmarked at least 22 days before the next election in which you plan to vote. A
qualied active-duty uniformed services member, spouse or dependent is NOT subject to the mailing deadline if by
reason of active duty, you are normally absent from the locality in which you reside.
All voters must show one acceptable, valid photo ID when voting in-person. For a complete list of acceptable forms
of photo identication visit: elections.virginia.gov/voterID . All acceptable forms of photo ID can be used up to a year
after the ID has expired.
#
WARNING: INTENTIONALLY VOTING MORE THAN ONCE IN AN ELECTION OR MAKING A MATERIALLY FALSE
STATEMENT ON THIS FORM CONSTITUTES THE CRIME OF ELECTION FRAUD, WHICH IS PUNISHABLE UNDER
VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IN PRISON, OR
UP TO 12 MONTHS IN JAIL AND/OR FINED UP TO $2,500.
Photo ID
Privacy Act
Notice
You may complete your voter registration application online at elections.virginia.gov/register . You may also check
your voter registration status online at elections.virginia.gov/status .
Go Online
Call your local voter registration oce or call (800) 522-9745 • TTY 711.
Questions?
Need more information? Go Online: elections.virginia.gov Or Call: (800) 552-9745 TTY: 711
General Registrar - 110 Old Chatham Elementary Lane, Chatham, VA 24531
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Form 1.: Virginia Voter Registration Application (Pittsylvania County Virginia)

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Completed 14 February 2021

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